Endometrial Cancer

Question 1

What is the pathophysiology of endometrial cancer?

Answer 1

Cancer can affect any organ in the reproductive tract. This chapter covers very common gynecologic cancers. Endometrial cancer (cancer of the uterine lining) is the most common gynecologic malignancy; its incidence continues to rise in the United States, with an estimated 65,620 new cases diagnosed annually).
Endometrial cancer grows slowly in most cases, and early symptoms of vaginal bleeding generally lead to prompt evaluation and treatment. As a result, this type of cancer has a generally favorable prognosis. Adenocarcinoma of the endometrium is the most common type of uterine cancer. Abnormal uterine bleeding (AUB) is the most common symptom, resulting from estrogen exposure that leads to endometrial hyperplasia. The initial growth of the cancer is within the uterine cavity, followed by extension into the myometrium and the cervix. Staging reflects the location of the cancer and whether it has spread. Categorized by histology, type I uterine tumors (the most common) result from endometrial hyperplasia (described above). Type II, which reflects 10% of endometrial cancers, are likely to invade the uterine muscle and metastasize Endometrial cancer is strongly associated with conditions causing prolonged exposure to estrogen without the protective effects of progesterone.

Question 2

What signs and symptoms are associated with endometrial cancer?

Answer 2

The main symptoms of endometrial cancer are:
- Abnormal uterine bleeding [AUB], especially postmenopausal bleeding. Ask the patient how many tampons or menstrual pads she uses each day.
- Some women also have a watery, bloody vaginal discharge or low back, low pelvis, or abdominal pain (caused by pressure of the enlarged uterus).
- Ask the patient to describe the exact location and intensity of her discomfort. A pelvic examination performed by the health care provider may reveal the presence of a palpable uterine mass or uterine polyp. The uterus is enlarged if the cancer is advanced.

Question 3

What labs are done?

Answer 3

Several laboratory tests are used to determine the overall condition of the woman with possible or confirmed endometrial cancer.
- A complete blood count may shows anemia due to heavy bleeding. Serum tumor markers to assess for metastasis include CA 125 (cancer antigen 125) and alpha fetoprotein (AFP), both of which may be elevated when ovarian cancer is present. A human chorionic gonadotropin (hCG) level may be obtained to rule out pregnancy before treatment for cancer begins.

Question 4

What diagnostics can be done?

Answer 4

• Transvaginal ultrasound and endometrial biopsy are the gold standard diagnostic tests to determine the presence of endometrial thickening and cancer. Saline may be infused during the ultrasound to improve the image of the uterine cavity. This allows for careful evaluation of the uterine cavity and any small lesions that may be missed on other diagnostic tests.
• Dilation and curettage (when the patient cannot tolerate an endometrial biopsy)
• Hysteroscopy (for better visualization of the endometrial cavity)
• Chest x-ray
• Whole-body imaging of chest, abdomen, and pelvis (CT, MRI, positron emission tomography [PET], or combined PET/CT can be used)
• Liver and bone scans to assess for distant metastasis

Question 5

What some nonsurgical management interventions?

Answer 5

Radiation Therapy
- Brachytherapy: The purpose of brachytherapy is to prevent disease recurrence. This procedure is used for women who have had their uterus and cervix removed (ACS, 2019). The upper part of the vagina is treated when a cylinder is placed inside it by the radiologist. In high-dose-rate (HDR) brachytherapy, each treatment takes about 10 to 20 minutes. While the radioactive implant is in place, radiation is emitted that can affect other people, so others will not be in the room. Inform the patient that she is restricted to bedrest during the treatment session to prevent dislodgment of the radioactive source. At the completion of treatment, the woman may go home the same day. There are no restrictions for the woman to stay away from her family or the public between treatments. Depending on the oncologist’s determination, treatments may be given weekly or daily for at least three doses.

• External Beam Radiation Therapy: External beam radiation therapy (EBRT) may be used to treat any stage of endometrial cancer in combination with surgery, brachytherapy, and/or chemotherapy. The treatment is given on an ambulatory care basis usually 5 days a week for 4 to 6 weeks, with each session taking less than 30 minutes. Tissue around the tumor and pelvic wall nodes also is treated. Teach the patient to monitor for signs of skin breakdown, especially in the perineal area; to avoid sunbathing; and to avoid washing the markings outlining the treatment site.

Drug Therapy
- Multiagent Chemotherapy: Multiagent chemotherapy is used as palliative treatment in advanced and recurrent disease when it has spread to distant parts of the body, but it is not always effective. For that reason, it is important to also consider other methods of palliative care.
A common side effect of chemotherapy used to treat endometrial cancer is alopecia (hair loss). Remind the patient of this possibility before treatment starts.

Question 6

What are some surgical management interventions?

Answer 6

The most common surgical procedure to address endometrial cancer involves the removal of the uterus, fallopian tubes, and ovaries (total hysterectomy and bilateral salpingo-oophorectomy [BSO]). Laparoscopy or robotic-assisted surgery is preferred when the disease is confined to the uterus, as these surgeries are usually less expensive and have fewer complications and shorter hospital stays. If minimally invasive surgery is not possible, laparotomy can be considered. Vaginal or abdominal hysterectomy are also options.

Question 7

What are some care coordination and transition management things that need to be considered?

Answer 7

• Home care after surgery for endometrial cancer is the same as that after a hysterectomy. Patients who are receiving chemotherapy or radiation therapy are treated on an ambulatory care basis.
• Most women are surprised by the fatigue caused by radiation and chemotherapy. Help the patient and her family plan daily activities around treatment requirements so that she can effectively pace herself.
• High doses of radiation cause sterility, and vaginal shrinkage can occur. Vaginal dilators can be used with water-soluble lubricants for 10 minutes three to four times weekly until sexual activity resumes, generally within 4 weeks.
• Often patients experience emotional crises because of the physical effects of cancer treatments. Radical hysterectomy may be seen as mutilating. Both radiation and chemotherapy have side effects that change physical appearance and body image. Women may have a grief reaction to these changes. The feelings of loss depend on the visibility of the loss and the perception or reality of loss of function. Help the patient adapt to the body changes. Using a calm and accepting approach, encourage self-management as soon as her physical condition is stable.
• Encourage patients and their families to discuss their feelings. Refer to support services such as a certified hospital chaplain or other spiritual leader, social worker, or counselor. In the United States, local American Cancer Society chapters provide written materials about endometrial cancer and information about local support groups.
• Death can occur with or without treatment. The goal is for the patient to meet and exceed the 5-year survival mark without a recurrence of disease. If the tumor recurs and cure is not likely, the woman and her family need to consider hospice care and whether she can be cared for in the home. If nursing care is needed at home, the hospital nurse or case manager makes referrals to a home health care agency. A referral to a social services agency may be needed if the patient needs financial assistance for treatment and long-term follow-up.

Question 8

What signs and symptoms should the nurse educate a patient receiving brachytherapy to report?

Answer 8

• Heavy vaginal bleeding
• Urethral burning for more than 24 hours
• Blood in the urine
• Extreme fatigue
• Severe diarrhea
• Fever over 100°F (38°C)
• Abdominal pain